<!DOCTYPE html>
<html lang="zh-CN">
<head>
<#include "shared/site-head.ftl">

</head>
<body>

<div class="container-fluid">
    <div ng-app="app" ng-controller="ctrl">
        <div class="row">
            <div class="col-lg-10">
                <form action="create-patient/submit" method="post">
                    <div class="form-group">
                        <label for="">PID</label>
                        <input type="text" class="form-control" ng-model="data.pid" placeholder="Enter PID">
                    </div>
                    <div class="form-group">
                        <label for="">First Name</label>
                        <input type="text" class="form-control" ng-model="data.firstName" placeholder="Enter First Name">
                    </div>
                    <div class="form-group">
                        <label for="">Last Name</label>
                        <input type="text" class="form-control" ng-model="data.lastName" placeholder="Enter Last Name">
                    </div>
                    <div class="form-group">
                        <select class="form-control" ng-model="data.action">
                            <option>Register In Patient</option>
                            <option>Register Out Patient</option>
                            <option>Preregister Patient</option>
                            <option>Update Patient</option>
                            <option>Marge Patient</option>
                        </select>
                    </div>

                    <div class="form-group">
                        <label for="">City</label>
                        <input type="text" class="form-control" ng-model="data.city" placeholder="Enter City">
                    </div>

                    <input type="button" class="btn btn-default" value="Submit" ng-click="submit()">


                </form>


            </div>

        </div>


    </div>
</div>
<script src="/js/internals/pix-client/pix.create.js?version=2016092600001"></script>
</body>
</html>